cms_WV: 11051
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11051 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 309 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide the necessary care and services to each resident, to assist them in attaining or maintaining the highest practicable physical well-being, by failing to obtain physicians' orders to define the parameters of use of specialty mattresses and/or side rails and failing to carry out a physician's order reducing the dosage of a medication. This affected four (4) of twenty-eight (28) sampled residents. Resident identifiers: #84, #129, #114, and #15. Facility census: 128. Findings include: a) Resident #84 During the general tour of the facility at 2:30 p.m. on 06/22/09, observation found Resident #84 in bed resting on [MEDICATION NAME] low air loss mattress with controls that allowed for different settings of firmness. Review of her care plan revealed an intervention, under the problem of wound care, for: "Pressure redistribution surfaces to bed." However, there was no evidence in Resident #84's record of a physician's order for use of this mattress or of the settings to be used. During an interview at 1:15 p.m. on 06/25/09, the director of nursing (DON - Employee #82) acknowledged the facility failed to obtain a physician's order for use of the specialty mattress and assumed the nurses were using the same settings that were being used for other residents. b) Resident #129 Medical record review, on 06/25/09, revealed Resident #129 was using a [MEDICATION NAME] mattress (for an alteration in skin integrity) in conjunction with side rails. Further review revealed there was no physician's order for the mattress or the side rails, and the facility did not complete a bed safety assessment or a side rail use assessment prior to implementing these interventions. (See also citation at F272.) c) Resident #114 Observation, at 11:00 a.m. on 06/25/09, revealed this resident was lying on a low air mattress which had a raised border surrounding it. The resident also had raised half (1/2) side rails. Review of the resident's current physicians' orders revealed no order for this mattress or the side rails. Further review revealed the mattress (Stat 4000 Multizone Mattress coverlay with settings Float Mode: 4.0, 5.5, 6.0, 5.0,3.5, 1.5) had originally been ordered on [DATE], but the order had not been carried forward to the resident's current orders. d) Resident #15 Review of Resident #15's medical record, on 06/23/09, disclosed a "Consultation Report" completed by the facility's contracted pharmacist consultant. This document, dated as completed on 10/28/08, recommended to the physician that the continued use of Nerium 40 mg daily to exceed twelve (12) weeks should be accompanied by a documented rationale for continued use. The DON had written a message to the physician on the bottom of the form asking to change the dose of Nerium to 20 mg daily. On 11/28/08, the resident's attending physician addressed the recommendation by stating "as below". According to the DON, when questioned on 06/23/09 at 11:00 a.m., this statement indicated he would like to change the order to Nerium 20 mg daily. Further review of the resident's current medical regimen disclosed this order had never been carried out by facility staff. The resident continued to receive Nerium 40 mg daily. . | 2014-09-01 |